WWhat’s upsetting Ms. J. isn’t the six hours she waited in the emergency room to see a doctor about a growing and surprisingly painful sore on her leg. Or that she’s being examined in an ad hoc area in the triage area because the ward’s rooms are filled with patients waiting to be admitted to the secured infirmaries upstairs. What upset her is that when she asked the triage nurse in the waiting room a few hours earlier for a blanket, she was told, “I’m sorry. I can’t give you any.”
“A blanket!” screams Mrs. J. “That’s all I asked for.”
The triage sister who is with us is fighting back tears. She wanted to give Ms. J. a blanket, but the 60 patients in the waiting room complicated the situation. Past experiences left her little choice but to say no, although she denied herself the gesture of sympathy she was determined to give by refusing a cold patient’s request for a blanket, which also made her cold.
Why is an ER doctor like me brooding over blankets, especially hospital blankets, that are a little rough on the skin when sick people are flooding the country’s ER, ER, and hospitals?
Each wave of the pandemic has uncovered major, well-reported failures in the healthcare system, including shortages of beds in hospital wards and intensive care units, shortages of qualified staff, unfortunate outcomes due to boarding and waiting times, and the emotional toll on healthcare workers. But there are less obvious challenges, seemingly insignificant, that are harder to articulate and devastating in their own way.
The triage nurse later told me she had a hard time telling Ms. J. about a night in the ER before the pandemic when handing out a few blankets to patients in a crowded waiting room blew up in the staff’s faces. More patients asked, then demanded blankets. Family and friends came forward. Blankets went out the door. Once one was issued, it became impossible to draw the line. And when supplies ran out, patients didn’t believe it. Employees faced anger and abuse.
At some point it would happen that the empty carts would be loaded with blankets again. It takes a phone call and time. But these and other similar experiences corrode the soul of healthcare workers, and there are no ready fixes. The standard response to preserving what is left of our compassion involves emotional withdrawal, which we have discovered further undermines compassion.
Our ceiling problem is not really about ceilings. It’s a failure of something core that any system that has health and care as part of its title or mission should be able to sustain no matter the challenges.
I cannot talk about blankets without considering the benefits of the simple act of giving. Kindness and generosity are linked to parts of the brain associated with happiness and altruism, bringing physiological and emotional benefits to the giver, ranging from a warm glow to increased activation of brain regions and neurochemicals like oxytocin and endorphins associated with reward and trust are linked.
If giving is its own reward, I can’t help but wonder if there’s a price when doctors and nurses want to give something of a blanket and are unable to. I may be powerless to create more hospital beds or staff, but a blanket belongs at the lowest level of Maslow’s hierarchy of human needs, at the level of food, warmth, and shelter.
My encounter with Ms. J. took place during a previous wave of the pandemic. The pressures of yesteryear have only increased during Omicron, or so it feels, for ER, ICU, and infirmary staff. That’s partly because it’s been emotionally and physically taxing, and partly because this wave has grown on the backs of the unvaccinated.
Long before Covid-19 began changing the world, terms like “moral distress” and “moral injury” had entered the broader discussion of the struggles of healthcare workers. These terms are intended to capture the “mental, emotional, and spiritual distress” that results from the inability to uphold deep values and moral beliefs and to provide quality health care. I find these terms a bit vague. It is often used to describe and name the consequences of a range of challenging experiences for healthcare workers, but risks obscuring the complex and overlooked situations responsible.
I’m holding onto my moment with Mrs. J because I’m discovering that I’m losing the part of me that once worried about what it meant to not give a blanket to a patient with a cold. I feel so overwhelmed and powerless by everything I can’t do that I’ve erected a shameful line of self-defense: I’ve become emotionally empty.
Sometimes it’s easier to pretend I don’t see the needy faces and walk blindly past the moaning patients who wait in the hallways for hours. I pretend not to hear the frail man with dementia scream, “Doctor, Doctor.” I speed past the otherwise good-looking silver-haired woman, who has fallen and is lying still on a stretcher in pain from the stiff neck collar, immobilizing her cervical spine, digging into her chin.
I stop by because I’m busy with other patients, because I don’t want to give the impression that I’m their doctor when there are many patients in front of them, because I know that when you stop caring about one, it can happen quickly Person to take care of other worthy calls for my attention. I pass by often enough and that protective line of defense becomes what I am.
A valued emergency worker recently asked me, “Does everyone expect us to get out of this okay?”
We stood there in silence, not because we didn’t know the answer, but because it didn’t matter. Many healthcare leaders work a safe distance from broader problems and may not see why these seemingly small problems are profound and dangerous to clinicians and patients.
My apology to Ms. J. includes an explanation as to why she is not getting a blanket. She wipes the tears from her cheeks and nods. She expresses her sympathy for the stresses that hospitals and emergency room staff are subjected to. However, the ceiling is another matter. “Is it too much to give me a blanket?”
I am ashamed and angry to be part of a system that places health workers in positions where meeting a basic human need becomes a form of risk management.
Not long ago, a woman who sat in the waiting room for half a day yelled at me when she was finally taken to one of the ER rooms and I felt nothing. I made her scream. I told her in a calm, dejected tone that she could yell at me whatever she wanted. I would scream too if I were in her place. I’m surprised that patients don’t scream more often, even though we’re doing our best. But we’ve been at this for two years, and most of us are just a shell of what we used to be, and more shouting isn’t going to make things better. And there’s a chance — unlikely but possible — that there will come a day when she walks into the ER only to find it’s dark because there’s no one to staff her. So gone we are.
I couldn’t believe I told her what I was experiencing if her issues were to be the focus of this interaction. I felt guilty for disregarding the one-way street sign of the doctor-patient relationship.
She stared at me, swallowed, and then apologized. And I apologized to her. No, she said. She felt terrible. No, I insisted I felt terrible. We soon got into a verbal battle over who deserved the apology and who should receive it.
The pandemic has brought to light what most of us who work in emergency rooms and hospitals have known for years: the house of medicine is collapsing. As standards and due diligence crumble and medical professionals struggle to make the “best bad decisions,” it’s hard to lose sight of the possible and ask, “What can we do in this catastrophe of not giving?”
One adaptation that has emerged from this pandemic crisis is to embrace technology such as digital health and telemedicine. But connectivity via a video screen is not the solution when there is a connectivity problem at the ceiling level, when conditions turn ceilings into a moral crisis.
Any meaningful work on restoring health care needs to start here, by examining the broader issues that data and graphs under-capture. They may seem simple, but they are anything but simple. These rocky moments provide opportunities for stability and sources of comfort and control. I find hope in the knowledge that some critical system solutions are only an arm’s length away, even though the answer is no longer ceilings. It recognizes and meets the basic needs of those who belong to these poor: frontline workers who want to provide compassionate care and patients who deserve to receive it even in a crisis.
Jay Baruch, MD, is Professor of Emergency Medicine and Director of Medical Humanities and Bioethics at Brown University Alpert Medical School and author of the forthcoming book Tornado of Life: Constraints and Creativity in the ER (MIT Press , Fall 2022) . The patient’s name and identification details have been changed to protect patient privacy.